2012 Part D Appeals and Exceptions

Coverage Determination is a decision about whether a drug prescribed for you is covered by the plan and the amount you are required to pay for the prescription. The coverage determination process includes determining requests that asks us:

• To approve a prior authorization for a drug.
• To approve a formulary or tier exception.
• To pay for our share of the costs of a drug that you have received.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan; that is not a coverage determination. The Coverage Determination process starts when you or your doctor requests a formal decision about the coverage.

For Prior Authorization

• You or your doctor may complete the Coverage Determination form.
• To speed up the prior authorization request, we suggest that your doctor complete the prior authorization form for the specific drug you need, and fax the completed form, along with any supporting documentation, to the number on the form.
• You can find your drug's Prior Authorization form on our formulary page by clicking on the "Drugs that Require Prior Authoization" link.
• For more detailed information, see the "How do I get prior authorization?" above.

For Formulary or Tier Exception

• You or your doctor may complete the Coverage Determination form.
• To speed up the formulary or tier exception process, your doctor should send supporting documentation for the request.
• For more detailed information, see "How do I get an exception?" section.

For Payment on Our Share of the Costs of a Drug that You Have Received

• Sometimes when you get a prescription drug out-of-network or a vaccine at the physician's office, you may need to pay the full cost right away.
• Other times, you may find that you have paid more than you expected under the coverage rules of the plan.
• In either case, you can ask our plan to pay you back (paying you back is often called "reimbursing" you).

How and Where to Send Us Your Request for Payment

You may have to file for reimbursement for drugs purchased from an out-of-network pharmacy, for drugs administered by your physician, or for the cost of vaccine administration from your physician. The reimbursement process in each of these instances is described below.

Getting Reimbursement for Drugs Purchased at an Out-of-Network Pharmacy

We suggest that you:

• Complete a Direct Reimbursement Claim form
• Send us this form along with the Pharmacy Label or a Pharmacy Prescription Claim History.
• You may also choose to complete the Coverage Determination form.

The Pharmacy Label is generally attached to your prescription bag when you pick up your medication. The Pharmacy Label indicates:

• The name of the drug
• The quantity
• The date of purchase
• The cost of the drug

If you have misplaced the Pharmacy Label, you can ask the Pharmacist for a Pharmacy Prescription Claim History, which will include information on the name of the drug, the quantity, the date of purchase and the cost of the drug. You will need to mark the drug on the claim history form for which you are requesting payment.

Getting Reimbursement for Vaccines Obtained from the Physician

• Complete a Direct Reimbursement Claim form.
• Send us this form along with a detailed physician's office receipt showing the date and the cost of the vaccine and your payment.

Getting Reimbursement for Vaccines Administered by Your Physician or a Network Pharmacy That Has Not Contracted with Medi-CareFirst for Vaccine Administration

• Complete a Direct Reimbursement Claim form
• Send us this form along with the receipt showing the date and cost of the vaccine administration and your payment.

Important Note

You do not have to use the Direct Reimbursement Claim form but the use of this form will speed the reimbursement process.

• Download a copy of the "Claim Form," or
• Call Claims Customer Service at 1-800-693-1434 (TTY users call 1-800-693-0765) 24 hours a day, 7 days a week and ask for the form, or
• Mail your request for payment together with any receipts to:
  Medicare Prescription Drug Plan Claims Customer Service
  c/o Argus Health Systems Dept. #303
  PO Box 419019
  Kansas City, MO 64141

Approval in advance for certain prescription drugs or medical services. If Prior Authorization is not received, Medi-CareFirst may not pay for your drug or service.

You or your doctor may complete the Coverage Determination form. To speed up the prior authorization request, we suggest that your doctor:

• Complete the drug's prior authorization form for the specific drug you need..
• Fax the completed form along with any supporting documentation to the number on the form.

You can access the list of drugs that require Prior Authorization on our formulary page by clicking on the "Drugs that Require Prior Authorization" link.

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A request to Medi-CareFirst to pay for a drug that is not covered, to pay for a drug at a different cost, or to waive restrictions or limits on your drug.

You or your doctor may complete the Coverage Determination form. To speed up the formulary or tier exception process, your doctor should send supporting documentation for the request.

There are several types of exceptions that you can ask us to make. Choose one of the boxes on the form to indicate the type of exception you need.

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medi-CareFirst limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit.
• You can ask us to provide a higher level of coverage for your drug. For example, if your drug is non-preferred brand-name drug, you can ask us to cover it as a preferred brand-name drug instead.This would lower the amount you must pay for your drug.

Generally, Medi-CareFirst will only approve your request for an exception if the alternative drugs included on the plan's formulary or the lower-tiered drug would not be as effective in treating your condition, and/or it would case you to have an adverse medical reaction.

Please Note:

• You cannot get a brand-name drug and pay a generic drug copay.
• If we grant your request to cover a drug that is not on our formulary, we will not change the pricing level for that drug.

You or your doctor may fax or mail the completed Coverage Determination form and any doctor's supporting information. However, to speed up the exception request, we suggest that your doctor complete the Coverage Determination form and fax the completed form along with any supporting document to the following fax number.

Fax to:
Medicare Prescription Drug Plan Claims Center
Attention: Prior Authorization Department
Fax: 1-800-315-4025 (This fax machine is located in a secure location as required by HIPAA regulations.)

Mail to:
Medicare Prescription Drug Plan Claims Center
c/o Argus Health Systems
Dept #303
PO Box 419019
Kansas City, MO 64141

You will receive a decision within 72 hours after it is received.

*Your prescribing doctor must give us a written statement telling us why you need this exception.

You or your doctor may also call to request an exception
Call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

If waiting 72 hours for a decision could seriously harm your life or health, you can ask for an expedited (fast) decision:

• Ask your prescribing doctor to call us at 1-800-932-0169.
• The doctor must tell us that waiting 72 hours for a decision could seriously harm your life or health.
• Your prescribing doctor could also use the Coverage Determination form and fax it, as noted above.

You will receive a decision within 24 hours of when the expedited exception is requested. If we don't hear from your doctor, Medi-CareFirst will decide if your health condition requires a fast decision.

Additional information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2012: Evidence of Coverage

• BlueRx Standard (PDP) (1.80 MB, 156 pgs., PDF)*
• BlueRx Enhanced (PDP) (1.46 MB, 144 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A request to reconsider and change a decision made about a health care service, drug authorization, or prescription or medical claim.

If you do not agree with a decision, you have the right to appeal. To begin the appeals process for either a fast (expedited) or standard appeal, or to follow up on an appeal, call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

They will give you specific instructions, depending on the nature of your request.

If you prefer, you can write to the Appeals Unit. Written fast (expedited) or standard appeals can be sent via fax or mail:

Fax to:
Medicare Central Appeals Unit
410-605-2566 or 888-415-7311

Mail to:
Medi-CareFirst BlueCross BlueShield
Central Appeals Unit
PO Box 17636
Baltimore, MD, 21298-9375

The following is the full appeals process:

Level 1 – Appeal to the Plan
You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan "redetermination." When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look. If the plan says no to all or part of your Level 1 appeal, you can go to a Level 2 (IRE) appeal.

Level 2 – Independent Review Entity (IRE)
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.

Level 3 – Administrative Law Judge (ALJ) Hearing
If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part D drug you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record, and be represented by counsel.

Level 4 – Medicare Appeals Council (MAC)
If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).

Level 5 – Federal Court
You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council's decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:

• The decision is not completely favorable to you, or
• The decision tells you that the MAC decided not to review your appeal request.

More Information:
More information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2012: Evidence of Coverage

• BlueRx Standard (PDP) (1.80 MB, 156 pgs., PDF)*
• BlueRx Enhanced (PDP) (1.46 MB, 144 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A complaint about the way you receive your Medicare Prescription Drug or Health Plan's coverage. For example, if you do not like the way you are treated by the Medi-CareFirst staff when you call, you would file a grievance. (Note: if you are unhappy with a coverage decision, you would file an appeal.)

If you have any kind of problem with your plan, please call us at:

Membership Customer Service
1-888-857-6118
1-800-855-2880 (TTY)
October 15-February 14: 8 am - 8 pm, 7 days a week
February 15 - October 14: 8 am - 8 pm, Monday through Saturday.

We will try to resolve any problem during that call.

If we cannot solve your problem during that call, we will send your problem to someone in our company who can help you. They will then contact you.

If you want a written response to your phone call, we will respond in writing to you.

If you prefer to write or fax us about your problem:

Mail to:
Medicare Prescription Drug Plan Enrollment Center
c/o CGI Technologies & Solutions
P.O. Box 2668
Fort Worth, TX 76113

We will respond to your problem as fast as we can and no later than 30 days after the day we get it. There are times when we may need more information to resolve your problem. In these cases, we may need up to 14 more days. If we need more time, we will let you know.

Note: You must tell us about your problem no more than 60 days after it happened.

More Information

More information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

2012: Evidence of Coverage

• BlueRx Standard (PDP) (1.80 MB, 156 pgs., PDF)*
• BlueRx Enhanced (PDP) (1.46 MB, 144 pgs., PDF)*

*Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

A person who represents your interests when you are unable to represent yourself.

Complete the Appointment of Representative Form (106 KB, 2 pgs., PDF) and send it to:

Medicare Prescription Drug Plan Enrollment Center
c/o CGI Technologies and Solutions
P.O. Box 2668
Fort Worth, TX 76113

Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.